For people with chronic pain, cigarette smoking is associated with greater pain intensity and impairment. Researchers have hypothesized areciprocal relationship in which pain and smoking exacerbate each other, resulting in greater pain and increased smoking. This study aimed to qualitatively examine patient perspectives on this association. Aretrospective thematic analysis of smoking cessation counseling notes for 136 veterans in the Pain and Smoking Study, atailored smoking cessation trial, was conducted. Avalidated codebook was applied to each counseling note by four independent coders using Atlas.ti (Atlas.ti, Berlin, Germany). Coders participated in aconsensus-forming exercise with salient themes validated among the wider research team. Participants averaged 60years of age (range 28-77years) and were 9% female. The median number of cigarettes smoked per day was15, with amean pain intensity score in the last week (from 0-10) of 5.1. While not all patients acknowledged aconnection between pain and smoking, we found that (1)pain motivates smoking and helps manage pain-related distress, as acoping strategy and through cognitive distraction, and (2)pain motivates smoking but smoking does not offer pain relief. Concerns about managing pain without smoking was identified as anotable barrier to cessation. Many patients with chronic pain who smoke readily identified pain as amotivator of their smoking behavior and are reluctant to quit for this reason. Integrated interventions for smokers with pain should address these perceptions and expectancies and promote uptake of more adaptive self-management strategies for pain.
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